Outcomes and risk factors in 1,609 carotid endarterectomies.

Severe carotid stenosis is typically treated with carotid endarterectomy (CEA), but there is debate about the safety of this procedure in patients with occlusion of the contralateral artery, previous CEA in the same artery, and other risk factors. To evaluate the association of these factors with outcomes in standard CEA with Dacron patch angioplasty, we examined the records of 1,609 consecutive isolated CEAs performed at our institution over a 10-year period on 1,400 patients (851 men and 549 women; mean age, 69.5 yr) with symptomatic or high-grade asymptomatic carotid lesions. Twenty-three patients (1.4%) had perioperative strokes, of which 2 were fatal. The overall same-admission mortality was 0.2% (4 patients). Same-admission stroke/death was more likely in patients with any history of tobacco use (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.6-13.6), contralat-eral occlusion (OR, 3.3; 95% CI, 1.2-9.1), angina with a Canadian Cardiovascular Society classification of 2 or greater (OR, 3.2; 95% CI, 1.4-7.6), or transient ischemic attack within the 6 weeks before surgery (OR, 2.4; 95% CI, 1.05-5.3). A total of 9 patients (0.6%) died within 30 days of CEA; our multivariate analysis did not reveal any significant predictors of 30-day mortality. We conclude that standard CEA with patch angioplasty is associated with low rates of death and morbidity for most patients, but patients with any history of tobacco use, substantial angina, contralateral occlusion, or preoperative transient ischemic attack may have an elevated risk of adverse outcomes.

Emergency percutaneous tracheostomy after unsuccessful orotracheal intubation in a patient with an acute myocardial infarction.

A 41-year-old woman had acute respiratory failure related to a myocardial infarction. Attempts at orotracheal intubation were unsuccessful; therefore, an emergency percutaneous tracheostomy was performed. The patient was then taken to the cardiac catheterization laboratory for myocardial revascularization. After the tracheostomy cannula was removed, the patient recovered successfully and was discharged from the hospital. The percutaneous tracheostomy technique may be useful in similar patients who need emergency airway access.